You may have been asked to complete our Learning Behavior Questionnaire concerning your student’s learning skills. This form is a series of questions that yield a score to identify areas of concern. Your score and the answers to the questions will be kept in the strictest confidence.

Once you have completed the form, click Send, and upon receiving the Learning Behavior Questionnaire we will review the answers and email the results to you. There is no obligation of any kind to get these results. We will send you the results of the questionnaire and a letter with basic information about our services. You will not receive any further solicitations from this submission.

We never sell, share or trade your information with anyone.

Some of the typical questions we ask in our Learning Behavior Questionnaire are …

Have you and your child been hearing any of the these messages at teacher conferences where you are told that your student is …

“reading below grade level”

“performing below expectations”

“can’t stay on task”

“distracts easily”

“won’t follow instructions”

We also ask questions such as …

Does your student spend way too much time on homework?

Does your student read below grade level?

Is your student a slow and inaccurate reader?

Is your student a poor speller?

The answers to the questions will give us a first glimpse of your student and help us determine your student’s needs and a program to recommend, if one is needed. We want to emphasize that our programs are interventions, not life-long commitments. Our programs are specific, research based, intensive, one-on-one Academic Therapy that help an individual overcome their learning problems.

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Name *

Student's Name *

Phone

E-mail *

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Comments

Please read each of the following statements and rate your student by selecting a number from 0 to 4 for each statement. Be sure to complete all the items.

When you have completed the Questionnaire select the submit button at the bottom .

COMPARED TO OTHER STUDENTS THE SAME AGE...

0 - Occurs less often OR the question doesn't apply 1 - Occurs at about the same frequency 2 - Occurs slightly more 3 - Occurs considerably more 4 - Occurs very considerably more

Q1 - Is careless

0 1 2 3 4

Q3 - Swears or uses obscene language

0 1 2 3 4

Q5 - Has difficulty maintaining attention

0 1 2 3 4

Q7 - Loses temper

0 1 2 3 4

Q9 - Has difficulty organizing activities

0 1 2 3 4

Q11 - Argues with adults

0 1 2 3 4

Q13 - Fails to follow through on tasks

0 1 2 3 4

Q15 - Refuses adults' requests or rules

0 1 2 3 4

Q17 - Takes a long time to complete tasks

0 1 2 3 4

Q19 - Deliberately annoys others

0 1 2 3 4

Q2 - Fidgets or squirms

0 1 2 3 4

Q4 - Often asks to have things repeated

0 1 2 3 4

Q6 - Overreacts

0 1 2 3 4

Q8 - Has poor study and work habits

0 1 2 3 4

Q10 - Leaves seat in class

0 1 2 3 4

Q12 - Reverses letters or words

0 1 2 3 4

Q14 - Runs or climbs excessively

0 1 2 3 4

Q16 - Feels school work is too hard

0 1 2 3 4

Q18 - Has difficulty playing quietly

0 1 2 3 4

Q20 - Does not complete assignments

0 1 2 3 4

COMPARED TO OTHER STUDENTS THE SAME AGE...

0 - Occurs less often OR the question doesn't apply 1 - Occurs at about the same frequency 2 - Occurs slightly more 3 - Occurs considerably more 4 - Occurs very considerably more

Q21 - Avoids prolonged mental effort

0 1 2 3 4

Q23 - Blames others for mistakes

0 1 2 3 4

Q25 - Is distracted by other activities

0 1 2 3 4

Q27 - Is angry and resentful

0 1 2 3 4

Q29 - Does not listen

0 1 2 3 4

Q31 - Holds grudges and seeks revenge

0 1 2 3 4

Q33 - Poor spelling grades or test scores

0 1 2 3 4

Q35 - Poor reading comprehension

0 1 2 3 4

Q37 - Poor math grades or test scores

0 1 2 3 4

Q39 - Makes spelling errors on assignments

0 1 2 3 4

Q22 - Answers before questions completed

0 1 2 3 4

Q24 - Has difficulty remembering

0 1 2 3 4

Q26 - Has difficulty waiting for turn

0 1 2 3 4

Q28 - Has difficulty learning math facts

0 1 2 3 4

Q30 - Is touchy or easily annoyed by others

0 1 2 3 4

Q32 - Difficulty with abstract concepts

0 1 2 3 4

Q34 - Worries about future events

0 1 2 3 4

Q36 - Has poor handwriting

0 1 2 3 4

Q38 - Worries about past behaviors

0 1 2 3 4

Q40 - Squints, blinks, rubs eyes when reading

0 1 2 3 4

COMPARED TO OTHER STUDENTS THE SAME AGE...

0 - Occurs less often OR the question doesn't apply 1 - Occurs at about the same frequency 2 - Occurs slightly more 3 - Occurs considerably more 4 - Occurs very considerably more

Q41 - Dislikes school

0 1 2 3 4

Q43 - Difficulty sounding out unknown words

0 1 2 3 4

Q45 - Makes grammatical errors

0 1 2 3 4

Q47 - Past ear infections or speech problems

0 1 2 3 4

Q49 - Poor reading grades or test scores

0 1 2 3 4

Q51 - Needs words repeated for spelling tests

0 1 2 3 4

Q53 - Receives low test scores

0 1 2 3 4

Q55 - Avoids reading

0 1 2 3 4

Q57 - Has difficulty writing a paper

0 1 2 3 4

Q59 - Reading is slow or choppy

0 1 2 3 4

Q61 - Has poor vocabulary

0 1 2 3 4

Q63 - Difficulty reading or spelling phonetically

0 1 2 3 4

Q42 - Concerned about what others will think

0 1 2 3 4

Q44 - Has difficulty hearing

0 1 2 3 4

Q46 - Is overly concerned about him/herself

0 1 2 3 4

Q48 - Has poor coordination

0 1 2 3 4

Q50 - Needs reassurance in many areas of life

0 1 2 3 4

Q52 - Has speech difficulties

0 1 2 3 4

Q54 - Complains about physical discomforts

0 1 2 3 4

Q56 - Complains about eye strain or fatigue

0 1 2 3 4

Q58 - Appears tense or unable to relax

0 1 2 3 4

Q60 - Is bothered by loud sounds

0 1 2 3 4

Q62 - Fears taking tests

0 1 2 3 4

Q64 - Skips words or lines when reading

0 1 2 3 4

Whew... That was a long form.

We respect your privacy, and will not share your information with anyone.